ORIGINAL ARTICLE
Healthcare Management Forum
A model of an agile organization designed
to better manage the COVID-19 crisis
Fabrice Brunet, MD1,2 ; Kathy Malas, MPO1,2 ;
and Danielle Fleury, MN1
Abstract
COVID-19 strongly hit healthcare organizations due to three factors: the lack of knowledge of this new virus, the fear of the
people, and the continuous modifications in the management of the crisis. This situation required flexibility and adaptability of
organizations, as our university health centre demonstrated. It relied on a decentralized model of management based on three
pillars: a culture of innovation and creativity, an agile organizational structure, and an open innovation ecosystem and network.
These assets were already developed prior to the onset of COVID-19 and helped our organization to better respond to the crisis.
Introduction
All healthcare systems and organizations around the world
were strongly hit by COVID-19. Their response depended on
their agility and capacity to adapt to the magnitude and severity
of this new and infectious disease. This crisis was
unprecedented in its rapid spread and its economic, political,
and social impact, which directly and indirectly affected both
healthcare workers and the general population.
We want to share how our university health centre in
Canada enhanced its response to the crisis using an organic
enterprise model.1
Three pillars in developing an organic
enterprise prior to COVID
Over the last 5 years, the Centre hospitalier de l’Université de
Montréal (CHUM) has developed and implemented a new
organizational model to enhance its adaptability and agility
when responding to successive crises, following the
amalgamation of three old hospitals into a new one. Before
the onset of the pandemic, CHUM had introduced a new
vision of a dynamic organization which would harness
innovation and creativity to better respond to the needs and
demands of the population, using a model of organic
enterprise as described by Mintzberg.1 This model is based
on three pillars: (1) a culture of creativity and innovation
supported by leadership and “communityship” (2) an agile
organizational structure and mechanisms, and (3) an open
innovation ecosystem and network (Figure 1).
The culture of creativity and innovation was an essential
pillar in our transformation. Every individual and team
contributed their experience, knowledge, and expertise to
solve problems in their local context and thus to better
respond to the needs of patients and teams. Recognizing
these different areas of expertise and talent was also an
essential component of the culture. The CHUM developed a
talent management office to enable every individual to develop
their own skills and career pathways according to their personal
and professional goals. Furthermore, offering individuals and
2021, Vol. 34(2) 115-118
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teams time not only to produce and deliver care but also to
explore encourages them to be inventive and consider new
solutions.
This culture was promoted by a vision-oriented and reason-
focused leadership: a consistent emphasis on innovation by local
teams2 to constantly improve the health and well-being of people
and the performance of the organization. Managers of all levels
were in close communication with frontline workers and teams,
clearly expressing the overall vision and attending to their needs
and problems, to make them feel empowered. Patient
partnership are a fundamental component of our mission and
they are part of our interdisciplinary teams. The CHUM in
collaboration with the Centre of Excellence on Partnership
with Patients and the Public have more than 3,000 patients and
citizen partners who collaborate in different innovative projects
in care, research, education and strategic committees.
Leadership was complemented by a strong sense of
community within the organization. “Communityship” is
achieved when every individual exercises leadership and
partnership and works together towards a set of common
goals. 3,4 This “communityship” was nourished by both
informal and formal activities, such as communities of
innovation, brainstorming sessions, and cooperative
competitions, which amplified creativity and strengthened
commitment.
The innovation of individuals and teams is also essential to
our second pillar, which proposes an ambidextrous and agile
organizational structure.5,6 The CHUM implemented such an
organization and capitalized on top-down, bottom-up and
transversal mechanisms.7 It assigned expert innovators to the
1
Executive Office, Centre hospitalier de l’Université de Montréal, Montreal,
Quebec, Canada.
2
Research Centre, Centre hospitalier de l’Université de Montréal, Montreal,
Quebec, Canada.
Corresponding author:
Kathy Malas, Research Centre, Centre hospitalier de l’Université de Montréal,
Montreal, Quebec, Canada.
E-mail: kathy.malas.chum@ssss.gouv.qc.ca
116
Figure 1. CHUM’s organic model. CHUM indicates Centre hospitalier de l’Université de Montréal.
task, aided by a transversal pole of innovation and Artificial
Intelligence (AI) in health, which enhanced the expertise of
multiple teams.
Furthermore, coordination mechanisms were applied to
assist exploration and production functions, making sure
relevant and impactful solutions were introduced into care
and services. Communities of practices within the
organization promoted knowledge sharing, which accelerated
learning within and between multiple departments. Another
example of such a coordination mechanism is the innovation
cycle. This process takes ideas or problems and validates their
relevance while codeveloping, experimenting, implementing,
assessing their value and impact, and adopting them in
practices. This cycle promotes creativity, structures and
accelerates innovation, and capitalizes on learning. Also,
measuring impact and value for patients, teams, and the
organization is key in this process. At CHUM, we deployed a
systemic approach to measuring value, based on the quadruple
aim in health.8,9 To these four aims, CHUM adds knowledge
generation and mobilization in fulfilling its academic mission.
The third and final pillar is the open innovation ecosystem,
which amplifies creativity and innovation of individuals,
teams, and the organization.10 The CHUM has put in place
several knowledge and innovation networks, both locally and
internationally, that share experiences and collaborate on
projects. Within its organizational processes and practices, it
embedded the interdisciplinary and intersectoral partnership
from the project’s conception. This is translated by working
in an open mode from the need assessment or ideation and
Healthcare Management Forum
includes patients, healthcare professionals, researchers,
private industry partners, universities, and decision-makers.
This previously described transformation allowed CHUM to
cope with multiple internal and external crises, such as the
amalgamation of three hospitals into one, the Ebola crisis,
and the implementation of AI in practices. This culture,
combined with an agile structure, also prepared the teams to
quickly and appropriately respond to the new sanitary crisis.
Crisis management: Three factors countered
by three organizational pillars
Three factors in the COVID-19 crisis made its management
complex11 and influenced its global response. Firstly, the
disease was unknown and lacked standard of care. The
second factor was how vastly and rapidly the situation
changed, both locally and at government level, which
increased its complexity and uncertainty. And finally,
COVID-19 is a life-threatening disease, which generated a
high level of fear from patients and healthcare workers.
The COVID-19 crisis can be compared to trauma.12 Coping
mechanisms developed prior to a trauma can help an
individual, team, or organization respond to it. Hence,
CHUM relied on the three pillars established in its previous
transformation, as described above, to function as a response
mechanism in fighting this crisis.
To counter the first factor—the unknown nature of the
disease and the lack of pre-existing practices—real-time and
rapid integration of new knowledge, training, and experience
Brunet, Malas and Fleury
generated by experimentation and research was encouraged at
all levels of the organization. For example, the CEO and senior
management studied and followed international COVID-19
trends. Frontline clinicians and employees, researchers, and
experts in pedagogy worked together to develop new
protocols with known and unknown elements, testing them
rapidly with techniques such as simulation and diffusing
them at large to more than 7,500 healthcare professionals
within the hospital and other institutions. New research
protocols (more than 70), such as an image bank and biobank
with COVID-19 patients, were rapidly created to generate new
answers to unknown questions. Thus, the culture of innovation
helped multiple teams in mobilizing real-time knowledge to
counter the unknown. Frequent communications were used to
keep frontline workers and patients constantly informed of new
information.
As per the second factor, we mitigated the constant daily
changes by adopting an agile structure and managerial
mechanisms to respond rapidly. A crisis command centre
was created with senior management. Its role was to mitigate
these rapid changes in partnership with the CHUM community.
In addition to this, subcommittees were formed to pass from
strategic decision-making to operations, and vice versa. A
special tactic team was also introduced to quickly identify
needs and problems faced by local teams and address them to
the command centre. Local teams were invited to the command
centre to present their innovative practices. Teams promptly
experimented and implemented multiple solutions using an
interdisciplinary and intersectoral approach of monitoring
indicators of quality, security, and patient experience. This
adaptability was possible in a time of crisis due to the agile
organization and the coping and response mechanisms
developed prior to COVID-19. The teams felt a sense of
autonomy in decision-making and were able to connect with
different teams, the crisis command centre, and other
subcommittees when needed.
The third pillar in our previous transformation is the open
and inclusive innovation ecosystem. An example of such
initiative resulting from our ecosystem is the on-line
community of 3D printing and engineering. This community
was created and deployed in 3 days and included researchers,
engineers, clinicians, citizens, managers, procurement experts,
and private industry. They quickly identified the needs and
problems of clinicians and teams and tested and developed
3D solutions to shortages of personal protective equipment
and materials, such as 600 face shields printed per week and
COVID-19 swab testing. Another example is the opening of a
previously closed hospital for COVID and non-COVID
patients who were stable, yet incapable of returning to their
long-term facilities as they were still infectious. In less than a
week, CHUM, with the help of teams, volunteers, and other
healthcare professionals, opened a 180-bed hospital. More than
600 clinicians, hygiene and sanitation staff, and other
employees were recruited to support patients from the entire
Montreal healthcare network. This wouldn’t have been
possible without the culture of open creativity and innovation
117
and the structure, processes, and methods that already existed
within our organization.
Finally, to counter the last factor of fear from patients and
healthcare workers, leadership—from senior leaders to
frontline managers—made sure to constantly communicate
transparently and authentically to all frontline workers and
the CHUM community. Different communication strategies
were utilized, such as weekly live webinars with the CEO,
weekly meetings with unions, and a web platform for all
frontline managers and doctors to diffuse information and
answer questions in real time. Furthermore, supported by a
research project, we deployed a mobile application where
employees could self-screen their level of stress and anxiety.
This app also informed employees of support services, such as
the COVID psychological phone line. We offered mental
health prevention and intervention services for all employees
and teams that felt high levels of stress and anxiety. We also
helped to tackle the fear and stress of patients and families.
Furthermore, a COVID web platform and 24/7 phone line was
created for patients, and more than 4,800 patients benefited
from such services since March 15, 2020. A dedicated team
of nurses and trained employees was created and deployed to
answer families’ questions and accompany them in end-of-life
visits. More than 130 telephone support and links with clinical
teams were made, and 98 visits were made.
Lessons and perspectives for the second
wave
After the first wave, we learned three essential lessons. The
first is that the healthcare system can mobilize rapidly by
enabling and empowering people on the frontline. The speed
of our response, as well as the quality of care and safety
measures, was made possible by the collective commitment
of our teams and society as a whole. Some barriers, such as
regulatory and policy, were lifted, thus accelerating
innovation—for example, telehealth consultations at CHUM
passed from 700 in mid March to 14,000 in October 2020
after COVID.
The second lesson was the importance of pre-existing
coping mechanisms to fight crisis, which strengthened
resilience. Resilience of people, teams, and the organization
was one of the major observations during this pandemic,
which enabled rapid response and recovery. This was
possible thanks to patients and citizens, academic,
philanthropic and industry partners, frontline workers and
managers, who were all driven by vision and motivation to
offer the best and most secure care for patients and
employees. This commitment, sense of belonging to a
community, and ecosystem mobilization were made possible
by our organic organization, and the frontline workers and
teams finding their own local solutions. They were trusted
and listened to by senior and frontline management. Two
research projects are ongoing to document and measure how
our teams and organization were agile and resilient during this
COVID-19 crisis, enabling them to adapt rapidly to such
118
context. 13,14 As per patients and citizens partnership
involvement, we are conducting a research project to
measure the impact of nine technological and non-
technological innovation deployed during COVID-19 on
quality and security of care and patient partnership.15 From
those projects, one involved the deployment of patient
navigators for patients requiring breast cancer surgery (89
interventions of patient navigators for 56 breast cancer
patients) and another one is the citizen and volunteer support
line to break isolation for COVID and non-COVID patients
(more than 11,000 calls of volunteers to hospitalized
patients). Preliminary qualitative results show that patients
found high level of satisfaction receiving both these services.15
The third lesson was the importance of constantly
supporting the CHUM community and communicating
authentically and in real time. Psychological impact and
infection rates were mitigated by this approach (no deaths
among our employees and less than 1% infected). Multiple
supportive actions and means were deployed to protect and
support employees, such as the ones previously described,
plus the opening of a daycare for children of staff, free
parking, bonuses, and in-hospital COVID screening.
We are now in the second wave of the COVID-19 crisis. The
major problem will be the lack of human resources. Hence,
supporting people, not only at work but in their personal
lives, will be essential. Enabling creativity in people and
teams and prioritizing innovations that save frontline workers
time while addressing their fear, stress, and anxieties will be
key. We also need to continue enhancing and catalyzing the
adaptiveness of our organization and amplifying innovation in
our larger ecosystem by working with an interdisciplinary,
cross-sectorial, and inclusive approach.
Acknowledgements
We thank all departments, patients, citizens, frontline workers,
researchers, employees and partners of the Centre hospitalier de l’Uni-
versité de Montréal for their contribution and accomplishments during
this COVID-19 crisis which are translated in this article.
ORCID iDs
Fabrice Brunet, MD https://orcid.org/0000-0002-8121-8997
Kathy Malas, MPO https://orcid.org/0000-0001-8419-0507
Danielle Fleury, MN https://orcid.org/0000-0001-7209-1106
Healthcare Management Forum
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